Homeless Outreach Request

Homeless Outreach Request

This report will ensure anyone that needs connection to the homelessness response system is assessed for needs and connected to resources. In order to determine the appropriate outreach needed, we would like to understand what you observed, the location, and when it took place. We may need to contact you for more details, so please leave an email or phone number where you can be reached. An outreach team will be sent to assess for any needs. A health and safety assessment may also be conducted if necessary to ensure the health and safety of those experiencing unsheltered homelessness. Thank you for your information!

Reporter's Name

First and Last Name

Origin or Reporting Agency

Indicate private resident if you are not reporting as an agency.

Reporter's Email Address

Reporter's Phone Number

Observations

Please provide information of what you observed.

If you observed someone you suspect is experiencing homelessness, please describe what you observed:

This can include structures (e.g. tents or man-made structures), pets, description of person/people, etc. A detailed description of the individual(s) will help us to connect with the right person.

Resident First Name

If possible, please provide the name of the individual experiencing homelessness.

Resident Last Name

Resident Phone Number or Emergency Contact

If possible, please provide contact information (phone number, emergency contact, or email address) for the individual experiencing homelessness.

Resident Email Address

Non-Emergency Street Medicine Needed

Please note the Street Medicine team has limited capacity to address urgent referrals on dates between runs. If the client requires emergency evaluation, please call 911

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Type of service requested

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Number of People*

How many people did you observe?

Are there any minor children (under 18) in the household?*

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Is anyone in the household pregnant?*

Select

Address of Night-time Sleeping Site*

Location description (e.g. cross streets, address). Please be as detailed as possible and provide cross streets, landmarks, a nearby address, etc. so we are able to find the person in need.

Night-time Sleeping Site Location Description

Describe the type of site

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Are there any other details or comments?

Please provide any other helpful details, including site conditions and needs the individual(s) may have.

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